Making self care support work in the health service: The WISE approach

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Making self care support work in the health
service The WISE approach

• Whole System Informing Self-Management Engagement
  

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WISE Aim

• To make self care support part of every day
  routine in primary care
• Enabled by
• NPCRDC self-management group research
• Salford PCT support
• NIHR IBS programme grant
• NHS policy, need to improve ltc management

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WISE Approach
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What is Innovative?

• Core principles
• True whole system
• Include people from harder to reach backgrounds
• Theory and evidence focus throughout
• Build on existing skills
• Multidisciplinary development
• Practical and pragmatic
• Flexible and Evolving

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Tensions, Problems and RD Questions

• Getting innovation accepted by patients,
  practitioners and PCT
• The need to dumb down
• Finding a place for the patient voice in
  consultations
• How do you make innovation sustainable?
• Is primary care the right place for the WISE
  approach?

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Theories approaches NPT Whole
systems Sociology health illness Behavioural
change Learning organisation Patient centred
Informed by research Professionals - role
conflict Psychosocial needs challenge Restricted
model eg EPP Recursivity impact of
services Importance of service contact
Policy expectations Training Communicate
effectively Promote choice Risk
management Relevant information
Pre- clinical Phase 1 Phase 2 Phase 3
Formative Evaluation Interviews Observations Think
aloud Pre post consultation recording Satisfactio
n ratings
Informed by current practice Practice nurses give
most chronic care Guideline focused Accommodating
QOF
Training package
Outcome Patient receives appropriate and timely
self-care support ? improved ability to
self-manage ? improved health outcomes
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WISE in Salford
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Development Work

• Focus on Professional Training

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Development

• Decisions
• Whole practice
• 3 conditions Diabetes COPD IBS
• Logo
• Time needed for training 2 afternoons
• Patient information resources
• Training format and content
• System links

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Training Package

• Education components
• Training manual
• DVD
• Power-point slides
• Interactive components
• Mapping the patient journey
• Change planning skills
• WISE tools
• PRISMS
• Exploratory models
• Menu of options
• Consultation Skills
• How to assess what each patient can do and needs
  to do
• How to share decisions with patients
• How to make sure patients get the right support

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IBS only CBT Hypnotherapy
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Training Package

• Session 1 - WHOLE PRACTICE 3 hours
• Brief introduction to WISE
• Team building exercise
• Care pathways exercise small group work
• Planning change interactive session with whole
  practice
• Nominate a team within the practice to
  operationalise WISE
• Session 2 NOMINATED WISE GROUP ONLY
• Progress on getting WISE tools into practice
• Session 3 ONLY CLINICIANS 3 hours
• Refresh on WISE approach
• Show DVD plus discussion
• Skills training role play
• Discussion on how to ensure sustainability of WISE

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Tools

• PRISMS
• Explanatory model
• Menu of options

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Using the PRISMS Form

• Background
• PROMs and VCE
• Developed to focus consultation on patients
  agenda and support needs
• Clarify values and priorities
• Used to help decide self care support option

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PRISMS in Practice

• Its come from them and its very personal in a
  very user friendly way and its not a pressure at
  all, they feel comfortable with itif its
  brought out something very specific to them we
  can deal with it.
• Weve seen the tip of the iceberg but its opened
  up underneath that iceberg and weve found other
  things
• (Practice nurse id 5)

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The Explanatory Model

• Can be used to
• Highlight misplaced beliefs
• Make sense of problems
• Find out what the patient understands about
  management

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COPD Explanatory Model Example
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Patient Resources
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Menu of Self Care Support Options

• Information sources
• Web based information
• Guidebooks
• Group training and support
• EPP courses
• Group education
• Exercise classes e.g. Pulmonary rehab classes
• Voluntary sector and local support
• Patient support groups
• Health trainers
• IBS therapies CBT and Hypnotherapy

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Legitimising use of PRISMS
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IBS Therapies
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System and Organisation
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PCT Support

• Organisational level
• Vision for sustainability
• Funding and high level support
• Infrastructure
• Trainers
• Resource directory

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System Support

• NHS Salford now has a dedicated Self Care team
  who can help to implement the Whole Systems
  approach to self management. They can support
  you by
• Providing Self Care training, education and
  advice for patients and health care professionals
• Creating a directory of Self Care services across
  Salford and helping you to build an individual
  menu of options for your practice

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Salford Self Care Directory
www.salford.nhs.uk/healthguide
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Salford Self Care Directory
www.salford.nhs.uk/healthguide
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Learning Organisation

• Team building exercises
• Clinical and administrative staff rarely meet
  together
• Devised a sociable and enjoyable ice-breaking
  exercise
• Level playing field all equal
• Non-threatening
• Tactile

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Practice Logo
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WISE Research Learning

• Exploratory Study
• RCT and Health Economics
• Longitudinal Qualitative Study
• Process Evaluation

Funding NPCRDC NIHR Programme Grant Salford
PCT
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RCT and Process Evaluation Learning

• Reactions of practices
• Incentives
• Barriers
• Engagement with training
• Single-handed practices easier
• Team-building
• Struggle to provide self care support
• PRISMS a challenge to embed
• Incentivising patients to take part in RCT

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RCT

• Setting Salford PCT
• 40 practices, cluster RCT
• 1728 Diabetes
• 1728 COPD
• 1728 IBS
• Controlled follow-up 6 months, 12 months
• Postal questionnaire

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Current situation

• 2 dedicated trainers in post
• 32 practices recruited to training, 10 trained
• Data collection from 26 practices
• 6 and 12 month follow up started

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COPD DIABETES IBS TOTAL
Posted out (26 practices) 2022 2827 1634 6483
Baseline (ongoing 26 practices) 640 (32) 988 (35) 493 (30) 2121
Baseline complete (23 practices) 2117 (36)
6-month ongoing (19 practices) 254 458 249 961
6-month complete (12 practices) 768 (80)
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Looking Forward

• WISE has informed
• Manchester CLAHRC
• Community approach
• Whole Systems Demonstrator project
• CAPITOL - Care Planning
• International interest
• Australia PRISMS adaption Hep. C project
• Canada
• Scotland

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• Kennedy A, Rogers A, Bower P. Support for self
  care for patients with chronic disease. BMJ
  2007335968-70.
• Kennedy A, Chew-Graham C, Blakeman T, Bowen A,
  Gardner C, Protheroe J, Rogers A, Gask L.
  Delivering the WISE training package in primary
  care learning from formative evaluation.
  Implementation Science 201057.
• Kennedy A. Engaging in a shared vision for
  self-management the WISE approach. Diabetes
  Voice 54, 33-35. 2009
• Protheroe J, Blakeman T, Bower P, Chew-Graham C,
  Kennedy A. An intervention to promote patient
  participation and self-management in long term
  conditions development and feasibility testing.
  In press

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Salford Self Care Champions